Clinical Update

13 Mar Detection of NPS in Buprenorphine Samples

Synthetic Cannabinoids

Synthetic cannabinoids are among the oldest designer drugs in circulation, originally developed during research searching for compounds with medical properties similar to marijuana. Today, they are often used recreationally as alternatives to marijuana. They have been referred to as K2 or spice and are sprayed onto plant material and smoked or used in vaping devices. A synthetic cannabinoid was detected in 238 samples. Table 5 shows the breadth of synthetic cannabinoids detected in this study, with markers of MDMB-4en-PINACA and ADB-BUTINACA accounting for the majority of detections. Figure 4 further illustrates the top 10 analytes detected.

Hallucinogens/Dissociatives

Designer hallucinogens and dissociatives were developed to mimic the effects of PCP, LSD, or ketamine, while remaining legal. While testing orders for these substances is not as frequent as other classes, some of these substances were detected in nine samples. Analogs of PCP and ketamine were detected, as illustrated in Table 6 and Figure 5.

Miscellaneous NPS

Some NPS do not fit neatly into one of the previous classes for various reasons, so they are not included in previously discussed drug classes. These are found in Table 7. Xylazine has been the most notable substance detected in this grouping for the last three years and was detected in 1,653 samples. It is known to cause central nervous system (CNS) depression and many individuals exposed to it also develop skin and soft tissue infections which can result in amputations or systemic infections if left untreated. Tianeptine is sometimes referred to as “gas station heroin” because it is sold over the counter (OTC) in the US. In other countries, it is a prescription drug used as an antidepressant. Management of individuals exposed to tianeptine can be complex because of mixed actions at various receptors, including opioid receptors. In many cases, individuals use tianeptine for this effect at opioid receptors, either to replace an opioid, or to attempt to taper off an opioid. It was detected in 175 samples in this study. Phenibut is sold in many countries as a prescription anti-anxiety agent and was detected in 302 samples. Similarly to tianeptine, it is available as an OTC supplement in the US. Medetomidine has recently been detected in the illicit drug supply. Like xylazine, it contributes to CNS depression without activity at opioid receptors. Testing for medetomidine was introduced for clinicians in October, which is one reason it was only detected in 11 samples; however, it is not as prevalent in the illicit supply as xylazine (Figure 6).

Conclusion

This analysis demonstrated the potential for patients undergoing medication-assisted treatment with buprenorphine to continue substance use that could otherwise go undetected without specialized testing for NPS. Having definitive results regarding recent substance use allows for more transparency in clinical decision making that helps improve outcomes. A laboratory’s decision to offer NPS testing must be accompanied by a commitment to relevant and up-to-date testing, guided by established research organizations such as the Center for Forensic Science Research & Education, among others. This increases the likelihood of the test providing meaningful results that help with achieving treatment goals.

NOTICE: The information above is intended as a resource for health care providers. Providers should use their independent medical judgment based on the clinical needs of the patient when making determinations of who to test, what medications to test, testing frequency, and the type of testing to conduct.

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